Carotid artery stenting

Carotid artery stenting: still burdened by early trial results

The early randomized trial experience (CAVATAS, SPACE, EVA-3S, ICSS) comparing carotid artery stenting (CAS) and carotid endarterectomy (CEA) has been burdened by the limited experience of the interventionalists performing CAS. The periprocedural stroke excess with CAS observed in those trials has ever since affected carotid revascularization, especially in symptomatic carotid disease. Accordingly, no trial dedicated to this patient population has followed. In asymptomatic carotid disease, CREST, ACT-1 and ACST-2 have shown an equivalence in terms of combined periprocedural events as well as long-term protection from ipsilateral stroke or repeat revascularization between the two techniques. The management of patients with carotid stenosis should be multidisciplinary and decision to pursue medical management or proceed to revascularization in an individual patient should be based on his estimated stroke risk on medical management and his suitability for CEA and CAS. Since the majority of patients with carotid stenosis may qualify for both techniques, patient's perspective should be central in decision making.

[Diagnostic and Therapeutic Management of Carotid Artery Disease]

Diagnostic and Therapeutic Management of Carotid Artery Disease Abstract. A quarter of all ischemic strokes is caused by atherosclerotic obliterations of the extra- and intracranial brain-supplying vessels. The prevalence of atherosclerotic extracranial carotid stenosis rises up to 6-15 % from the age of 65. The risk of stroke in symptomatic carotid stenosis, i.e. after stroke or transient ischemic attack (TIA), is very high at 25 % within 14 days. Conservative therapy is the cornerstone of treatment by controlling the risk factors, treatment with platelet aggregation inhibitors and antihypertensive and lipid-lowering medication. Carotid endarterectomy (CEA) is the first line treatment for symptomatic patients with a >50 % and asymptomatic patients with a >60 % carotid stenosis. In order to ensure the best possible treatment of patients with asymptomatic and symptomatic carotid stenosis, interdisciplinary cooperation in diagnostics, therapy and aftercare in a neuromedical centre of maximum care is necessary.

Use of Micropatterned Thin Film Nitinol in Carotid Stents to Augment Embolic Protection

Stenting is an alternative to endarterectomy for the treatment of carotid artery stenosis. However, stenting is associated with a higher risk of procedural stroke secondary to distal thromboembolism. Hybrid stents with a micromesh layer have been proposed to address this complication. We developed a micropatterned thin film nitinol (M-TFN) covered stent designed to prevent thromboembolism during carotid intervention. This innovation may obviate the need or work synergistically with embolic protection devices. The proposed double layered stent is low-profile, thromboresistant, and covered with a M-TFN that can be fabricated with fenestrations of varying geometries and sizes. The M-TFN was created in multiple geometries, dimensions, and porosities by sputter deposition. The efficiency of various M-TFN to capture embolic particles was evaluated in different atherosclerotic carotid stenotic conditions through in vitro tests. The covered stent prevented emboli dislodgement in the range of 70%–96% during 30 min duration tests. In vitro vascular cell growth study results showed that endothelial cell elongation, alignment and growth behaviour silhouettes significantly enhance, specifically on the diamond-shape M-TFN, with the dimensions of 145 µm × 20 µm and a porosity of 32%. Future studies will require in vivo testing. Our results demonstrate that M-TFN has a promising potential for carotid artery stenting.